Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

A patient has a Glasgow Coma Scale score of 8. What is the main concern?

1. AThe patient only has a mild headache
2. BThe patient is fully alert and oriented
3. CThe patient may not be able to protect the airway
4. DThe patient can safely eat and drink without help

Using the RACE fire response, what does the nurse do first when finding a fire in a patient’s room?

1. ARescue patients in immediate danger
2. BClose doors to contain the fire and smoke
3. CUse an extinguisher on the fire
4. DPull the fire alarm

Taikant ABC schemą, kuri problema yra kraujotakos problema?

1. ANekontroliuojamas kraujavimas
2. B32/min kvėpavimo dažnis
3. CNerimas
4. DStridoras

A patient coughs hard after abdominal surgery, and loops of bowel appear through the opened wound. What does the nurse do first?

1. APush the bowel gently back into the abdomen with a gloved hand
2. BHelp the patient walk to the toilet to relieve abdominal pressure
3. CCover the wound with sterile dressings moistened with saline
4. DLeave the wound uncovered so the surgeon can see it on arrival

Before accessing a central venous catheter, what should the nurse do to prevent infection?

1. ARinse the hub with tap water and dry it
2. BTouch the hub to check it is clean
3. CScrub the hub with an antiseptic such as chlorhexidine and let it dry
4. DBlow on the hub to remove any dust before connecting the syringe or line

Pamainos vadovui reikia atlaisvinti lovą. Kuris pacientas tinkamiausias išrašyti ar perkelti į žemesnio lygio priežiūrą?

1. A3 diena po nesudėtingos apendektomijos, valgo, vartoja geriamuosius nuskausminamuosius
2. B1 diena po žarnyno operacijos su nauja 38,5 °C temperatūra
3. CPaguldytas prieš dvi valandas dėl krūtinės skausmo; troponino rezultatas dar nežinomas
4. DPneumonija, deguonies poreikis per naktį išaugo nuo 2 iki 4 L/min

On a cardiac step-down unit, which patient should the nurse assess first?

1. ASix hours after a coronary stent, new chest pain with ST elevation on the monitor
2. BHeart failure, weight up 0,5 kg since yesterday, no breathlessness at rest
3. CDay 2 after a pacemaker insertion, asking when the wound dressing will be changed
4. DAtrial fibrillation on warfarin with an INR of 2,6 this morning

At the end of a shift, the nurse’s relief has not arrived and the patients are acutely ill. What should the nurse do?

1. AAsk a nursing assistant to watch the patients until someone comes
2. BLeave on time, because the shift has officially ended
3. CStay and tell the charge nurse, and hand over before leaving
4. DLeave a written note at the station and go home